Population-Based Mental Health Facilitation (MHF): A Grassroots Strategy That Works

J. Scott Hinkle

Abstract: The World Health Organization (WHO) estimates that at least 450 million people worldwide live with unmet mental health problems. Additionally, one in four people will experience psychological distress and meet criteria for a diagnosable mental health disorder at some point in their lives. This data speaks to the need for accessible, effective and equitable global mental health care. Available mental health resources are inequitably distributed, with low- to middle-income countries showing significantly fewer mental health human resources than high-income countries. The need to proactively address this care-need gap has been identified by WHO and various national organizations, including NBCC International (NBCC-I). NBCC-I’s Mental Health Facilitator (MHF) program addresses the global need for community-based mental health training that can be adapted to reflect the social, cultural, economic and political climate of any population, nation or region.

Keywords: global, mental health, international, mental health facilitator, MHF, population, community, WHO

Pages 1–18

Developing and promoting mental health services at the grassroots level while also maintaining a global perspective is, to say the least, an overwhelming task. The National Board for Certified Counselors’ International division (NBCC-I) has responded to this task in two deliberate steps. Initially, NBCC-I collaborated with the World Health Organization’s (WHO) Department of Mental Health and Substance Abuse to establish the global Mental Health Facilitator (MHF) training program. The MHF program addresses the international need for population-based mental health training that can be adapted to reflect the social, cultural, economic and political realities of any country or region. Once the program was effectively addressed by WHO and NBCC-I as a viable strategy to reduce mental health issues on a global basis, NBCC-I independently developed a curriculum and implementation method that has begun to make a promising global impact (Hinkle, 2006, 2007, 2009, 2010a, 2010b, 2012a, 2012b, 2012c, 2013; Hinkle & Henderson, 2007; Hinkle & Schweiger, 2012; Schweiger & Hinkle, 2013).

For years the global burden of mental disorders on individuals, families, communities and health services has been considerably underestimated (Chisholm et al., 2000; Murray & López, 1996a, 1996b; Ustün & Sartorius, 1995). Resources for mental, neurological, and substance use disorders have been slow in development, insufficient, constrained, fragmented, inequitably distributed, and ineffectively implemented (Becker & Kleinman, 2013; Chen et al., 2004; Gulbenkian Global Mental Health Platform [GGMHP], 2013a; Hinkle & Saxena, 2006). While mental and neurological disorders comprise only 1% of deaths worldwide, they account for 8–28% of the disease burden (GGMHP, 2013a; Murray et al., 2012; Prince et al., 2007; WHO, 2004a), with the majority of these disorders occurring in low- to middle-income countries.

Mental Health: An International Problem

Most mental disorders are highly prevalent in all societies, remain largely undetected and untreated, and result in a substantial burden to families and communities. Although many mental disorders can be mitigated or are avoidable, they continue to be overlooked by the international community and produce significant economic and social hardship. Moreover, in all countries there is an enormous gap between the prevalence of mental disorders and the number of people receiving care (Becker & Kleinman, 2013; Saraceno et al., 2007; Weissman et al., 1994; Weissman et al., 1996; Weissman et al., 1997; WHO, 2010a, 2010b). In less-developed countries, more than 75% of persons with serious mental disorders do not receive treatment (Demyttenaere et al., 2004). Unfortunately, psychiatry’s best efforts at training physicians to provide mental health care within the global context are simply too small for such a large, global problem (Furtos, 2013; Hinkle, 2009, 2010b, 2012b, 2012c; Patel, 2013). The focus has been too long on medicine and not on local communities (Patel, 2013). In fact, every person’s health care is local (Unützer, 2013). The major issue with the current provision of care is, therefore, the limited size and training of the community health care workforce (Becker & Kleinman, 2013).

Globally, one in four people will experience psychological distress and meet criteria for a diagnosable mental disorder at some point in their lives (WHO, 2005). This ominous data speaks to the need for accessible, effective and socially equitable mental health care (Hinkle & Saxena, 2006). WHO estimates that more than 450 million people worldwide live with mental health problems; these numbers are no doubt bleak. More specifically, WHO estimates that globally more than 154 million people suffer from depression, 100 million are affected by alcohol use disorders, 25 million have schizophrenia, 15 million experience drug abuse, and nearly one million people die each year by suicide (Saraceno et al., 2007). Depending on the source, unipolar depression has been estimated to be in the top four causes of loss of disability-adjusted life years across the six socially diverse continents (Murray & López, 1996a, 1996b; Vos et al., 2012).

Furthermore, it has been estimated that as many as 25% of all primary care consultations have a mental health component (Goldberg & Huxley, 1992; Warner & Ford, 1998; WHO, 2006a). Mental disorders are related to a range of problems, from poverty, marginalization, and social disadvantage, to relationship issues such as divorce, physical conditions such as heart disease, reductions in economic productivity, and interruption of child and adolescent educational processes (see Alonso, Chatterji, He, & Kessler, 2013; Breslau et al., 2013). At the developmental level, at least 10% of children are considered to have mental health problems, but pediatricians and general medical practitioners are not typically equipped to provide effective treatment (Craft, 2005). With mental disorders contributing to an average of 20% of disabilities at the societal level, the evidence is clear that these disorders pose a major challenge to global health (Alonso, Chatterji, et al., 2013; Alonso, Petukhova, et al., 2013). Moreover, the associated economic burden exceeds that of the top four non-communicable diseases (i.e., diabetes, cardiovascular, respiratory and cancer; Bloom et al., 2011).

Unfortunately, most international mental health systems are dominated by custodial psychiatric hospitals that deplete resources for treatments with little efficacy (WHO, 2005). In contrast, governments and nongovernmental organizations (NGOs) should scale up services for community mental health with programs that reflect credible evidence of effectiveness (see Patel, 2013; Patel, Araya, et al., 2007). Murthy (2006) has indicated that there is no global community mental health blueprint to achieve universal mental health access, and that effective community workforce strategies need to be matched to each country’s unique situation. It is an ecological fallacy to try to understand people and mental health issues outside the environments in which they exist (Galea, 2013). Thus, a radical shift is urgently needed in the way mental disorders are managed, and this clearly includes community-based care that can be effectively implemented via non-health as well as health sectors (GGMHP, 2013a, 2013b; Hinkle, 2012b).

Global Community Mental Health

Serious mental disorders are generally associated with substantial role disability within the community. About 35–50% of mental health cases in developed countries and approximately 75–85% in less-developed countries have received no treatment in the 12 months preceding a clinical interview. Due to the high prevalence of mild and sub-threshold cases, the number of untreated cases is estimated to be even larger. These milder cases, which can be found in communities all over the world, require careful consideration because they are prone to progress to serious mental disorders (WHO, 2010a, 2010b; WHO World Mental Health Survey Consortium, 2004).

It is important to note that in most low- to middle-income countries, community workers are often the people’s first line of contact with the health care system (Anand & Bärnighausen, 2004; Hongoro & McPake, 2004). However, there is a long history of issues with the sustainability of community programs (Walt, 1988), and the lack of community service providers with the necessary competencies to address needs remains the most significant barrier to the provision of mental health services. Although human resources are the crucial core of health systems, they have been a neglected developmental component (Hongoro & McPake, 2004), particularly in the field of mental health. WHO’s “Mental Health Atlas” (2005) specifies a critical global shortage of mental health professionals (e.g., psychiatrists, psychiatric nurses, psychologists, social workers, neurologists). Similarly, an informal international survey of clinical mental health, school, and career and work counselors by NBCC-I indicated that the professional counselor workforce has yet to be adequately identified on a global scale (Hinkle, 2010b). Moreover, extant mental health services are inequitably distributed; lower-income countries, where behavioral risk factors tend to cluster among people of lower socioeconomic status, have significantly fewer mental health human resources than higher-income countries (Coups, Gaba, & Orleans, 2004; WHO, 2005; WHO World Mental Health Survey Consortium, 2004).

In low- to middle-income countries, human resources are clearly limited, and the quality and productivity of the existing workforce is often challenged. Investment in human resources for community mental health care is insufficient in absolute terms as well as in distribution (Hongoro & McPake, 2004). For instance, the global average for physicians is 170 per 100,000 people, but in Nepal and Papua New Guinea there have been as few as five doctors for this ratio (WHO, 2004a). In 2003, approximately 36% of doctors’ posts and 18% of nurses’ posts were unfilled around the world (Bach, 2004). Moreover, general practitioners are not typically adept at providing mental health care, including detection, referral and management of mental disorders (Chisholm et al., 2000). Therefore, partnerships between formal primary and informal community health care systems need to be more prevalent, effective and integrated.

Two facets for integrating mental health into primary care are (a) financial and human resources and (b) collaboration with non-health sectors. NGOs, community workers and volunteers can play a significant role in supporting formal primary care systems for mental health. For example, village health workers in Argentina, India and the Islamic Republic of Iran have been trained to identify and refer people for medical assistance. Even countries that have adequate services, like Australia, use local informal services to support mental health patients (see WHO, 2006b). Because psychiatric hospital beds are extremely limited, the demand for mental health services within communities becomes even more critical (Forchuk, Martin, Chan, & Jensen, 2005). Furthermore, early detection and treatment of mental disorders and co-occurring emotional and behavioral problems not only decreases the chance of lower physical health later in life, but also associated costly hospitalizations (Alonso, Chatterji, et al., 2013; Alonso, Petukhova, et al., 2013; Scott et al., 2013).

An urgent, radical change in the way mental disorders are managed and monitored—one that moves away from lengthy institutional hospitalizations and toward population-based mental health care in the community—is needed (GGMHP, 2013a, 2013b; Hinkle, 2009). The need to proactively address this care-need gap from a praxis, or practical, rather than a theoretical approach has been repeatedly identified by WHO and various national and international organizations, including NBCC-I (Hinkle & Schweiger, 2012). Communities in developing countries have historically lacked opportunities for mental health training, skill development, and capacity building (Abarquez & Murshed, 2004); however, long years of training are not necessary for learning how to provide fundamental help for people who are emotionally distressed.

Volunteer community workers are a large untapped community resource of potential service providers for people suffering from problems associated with mental health (Hoff, Hallisey, & Hoff, 2009). Chan (2010) has reported that “there is a widely shared but mistaken idea that improvements in mental health require sophisticated and expensive technologies and highly specialized staff. The reality is that most of the mental, neurological and substance use conditions that result in high morbidity and mortality can be managed by non-specialist health-care providers” (p. iii). The research has substantiated that it is feasible to deliver psychosocial-type interventions in non-specialized health care settings (WHO, 2010a, 2010b). Enhancing basic community mental health services, both informally and formally, is a viable way to assist the never-served. The MHF program is part of a grassroots implementation trend that has already begun in communities around the globe (e.g., Canada, Europe, Africa, Asia, United States; see Hinkle, 2007, 2013; Hoff, 1993; Hoff et al., 2009; Marks & Scott, 1990; McKee, Ferlie, & Hyde, 2008; Mosher & Burti, 1994; Patel, 2013; Rachlis & Kushner, 1994).

A Brief Review of Grassroots Community Mental Health Approaches

Unfortunately, governmental psychiatric hospitals have a long history of human rights violations and poor clinical outcomes (Hinkle, 2010b). They also are costly and consume a disproportionate amount of mental health care monies. In contrast, informal community caregivers are not generally part of the formal health care system; examples include traditional healers, professionals such as teachers, police and various community workers, NGOs, consumer and family associations, as well as laypeople. Informal care is typically accessible because it is an integral part of the community. However informal, this care should not replace the core of formal mental health service provision (Saraceno et al., 2007; WHO, 2010a, 2010b), but serve as a grassroots, adjunctive care system.

For example, beginning as early as 1963, the work of Rioch et al. portrayed community paraprofessionals serving as in- and out-patient “therapists.” Similarly, as far back as 50 years, Albee (1967) reported that the dearth of manpower in mental health services could be lessened by the use of paraprofessionals who could arrange for neighborhood outreach and basic psychiatric evaluations (Hines, 1970).

Likewise, in 1969 Vidaver suggested the development of mental health technicians with generalist skills for lateral and vertical mental health employment mobility. Vidaver (1969) further commented that community colleges were able to train local community helpers for a variety of informal roles in mental health services without years of higher education. Interviewing (i.e., communication), consultation, and community liaison techniques (i.e., referral) were depicted by Vidaver as important general skills for community helpers. One year later, Lynch and Gardner (1970) developed a training program with the goal of training laypeople to be “helpers in a psychiatric setting” (p. 1476), emphasizing communication skills training with a focus on the “front line of operation” (p. 1475) provided by paraprofessionals and professionals providing backup services.

Also in 1970, the U.S. military addressed mental health manpower shortages by increasing the use of paraprofessional specialists who were taught entry-level skills to help soldiers in need (Nolan & Cooke, 1970). Training included conducting interviews, collecting historical, situational and observational data, and developing referral skills to connect the soldier with professional mental health resources. Identifying common mental health problems and relating to problems in a realistic way were included in the training. Program evaluations indicated that trainees “quickly and confidently transpose their course-acquired skills to the job situation” (Nolan & Cooke, 1970, p. 79).

More recently, basic psychological first aid programs have been effective in Bangladesh, where psychosocial support is used in emergency situations (Kabir, 2011). As well, nurses and health care staff have been trained as mental health facilitators in the United Kingdom to recognize depression, anxiety, stress, drug and alcohol problems, grief reactions, and domestic violence; make referrals; and provide support and aftercare. These nurses also assist people with co-occurring disorders and provid mental health promotion in the schools. Furthermore, the nursing profession in the United Kingdom has noted that community mental health care is a particular problem area, resulting in the development of the mental health assistant practitioner as a creative practice strategy to reduce the costs of services as well as improve multi-professional communication based on local needs (Warner & Ford, 1998; Warne & McAndrew, 2004).

Although implementing such grassroots community mental health programs is not easy, global health care organizations have demonstrated greater need to develop innovative uses of informal mental health assistants and facilitators to establish community mental health services (Warne & McAndrew, 2004). In the long run, if the gap in mental health services is sufficiently closed, it must include the use of non-specialists to deliver care (Eaton, 2013; Eaton et al., 2011; Hinkle, 2006, 2009). Such non-specialized workers will have received novel training in identifying mental stress, distress and disorders; providing fundamental care; monitoring strategies; and making appropriate referrals (see Becker & Kleinman, 2013; Hinkle & Schweiger, 2012; Hinkle, Kutcher, & Chehil, 2006; Jorm, 2012; Saraceno et al., 2007).

The Mental Health Facilitator Training Program

Existing data speaks loudly to the need for accessible, effective and equitable global mental health care. However, a common barrier to mental health care is a lack of providers who have the necessary competencies to address basic community psychosocial needs. This barrier has been clearly identified by WHO and various national and international organizations, including NBCC-I (Eaton, 2013; Hinkle, 2006, 2009, 2012c; Hinkle & Saxena, 2006; Patel, 2013; WHO World Mental Health Survey Consortium, 2004; WHO, 2005, 2010a, 2010b).

General MHF Background Information and Rationale

In 2005, officers from NBCC-I met with the director of the WHO Department of Mental Health and Substance Abuse to discuss the challenges of international mental health care. As a result of these meetings, WHO selected 32 international mental health professionals to evaluate NBCC-I’s proposed MHF program, with almost 100% supporting its development. Subsequently, the curriculum and master training guide were completed by NBCC-I in 2007. Drafts of the curriculum and proposed teaching methods were piloted on two occasions in Mexico City with mental health professionals from Europe, the Caribbean, Africa and the United States. Additional subject matter experts facilitating pilot development included mental health professionals from Malaysia, Canada, Trinidad, St. Lucia, Turkey, India, Mexico, Botswana, Romania and Venezuela.

The resulting MHF training program draws on a variety of competencies derived from related disciplines, including but not limited to psychiatry, psychology, social work, psychiatric nursing, and counseling. Its eclectic programming and international composition allowed for a flexible training model with expertise drawn from global practices. Because MHF training is transdisciplinary, traditional professional helping silos are not reinforced; skills and competencies are linked instead to population-based mental health needs rather than professional ideologies. Thus, individuals with MHF training (MHFs) can effectively identify and meet community mental health needs in a standardized manner, regardless of where these needs are manifested and how they are interpreted. Mental health and the process of facilitating it is based on developing community relationships that promote a state of well-being, enabling individuals to realize their abilities, cope with the normal and less-than-normal stresses of life, work productively, and make a contribution to their communities.

The MHF training program was first taught in Lilongwe, Malawi in 2008 and has since been taught approximately 108 times by 435 trainers, including 181 master trainers in 20 countries. The MHF program recently expanded to provide mental health assistance in more established countries, as manifested in the program’s current popularity in the United States (Schweiger & Hinkle, 2013). This expansion also marks the completion of an educators’ edition of the MHF curriculum for use in schools with a focus on students, teachers and schooling.

To date, the MHF training program has been implemented globally to enhance mental health care at various levels. At the formal, primary health care level, general medical practitioners provide acute and long-term treatment to individuals with a variety of mental disorders, supplemented by the efforts of individuals with MHF training. MHFs also augment specialized services by functioning within a mental health care team to provide support, targeted assistance, referral and follow-up monitoring (Paredes, Schweiger, Hinkle, Kutcher, & Chehil, 2008). Likewise, informal community care is characterized by community members without formal mental health education or training providing much-needed services. At this level, nonclinical forms of mental health care such as psychological support or strategic problem solving by community leaders, family groups, and local elders (including indigenous healers) are emphasized. MHF training has been used to bridge the gap between formal and informal mental health care where MHFs work within both systems and do so simultaneously (Hinkle, Kutcher, & Chehil, 2006). With due respect to horizontal and vertical considerations, MHFs have augmented traditional, formal inpatient services by working with mental health teams to provide family support and education, monitor follow-ups, and provide practical “in the trenches” assistance (see Figure 1). This is where informal care, including self-care, becomes critical (Murthy, 2006).

Contextualizing the MHF Program

Most importantly, it is ill-advised to attempt to understand people outside their environments; people must be considered within the characteristics of their respective populations (Galea, 2013). The MHF program is designed to be flexible so local experts can modify components of the training to reflect the realities of their situation. Local stakeholders then identify and include specific competencies in their MHF trainings. As a consequence, consumers and policymakers ensure that MHF trainings provide culturally relevant services to the local population. Furthermore, the MHF training curriculum was conceived as a dynamic document and is revised once each year based on input from local institutions and individuals who provide MHF training. This contextual, organic approach grounds the MHF program in the principle that mental health care is a combination of both universally applicable and context-specific knowledge and skills (Furtos, 2013; Hinkle, 2012a; Paredes et al., 2008). The program consists of integrated knowledge ranging from basic mental health information and promotion to specific, local, culturally relevant helping strategies. The global MHF program

Figure 1. Modified WHO Pyramid Framework: MHF (Hinkle, 2013b)

provides equitable access to quality first-contact interventions, including but not limited to mental health advocacy, helping skills, and monitoring and referral, all of which respect human dignity and rights, and meet local population needs.

Individuals receiving MHF training represent a broad cross section of the community. Diverse trainee backgrounds increase the possibility of addressing the various gaps in local mental health care, which helps local policy makers, service providers, NGOs and communities meet mental health needs without costly infrastructural investments. Moreover, contextualized MHF training facilitates further development and delivery of community-based care consistent with WHO recommendations for addressing the gap in global mental health services.

Bottom-Up vs. Top-Down Community Strategies

It is commonly known that top-down approaches across public services generally have limited success. Conversely, long-term strategies that enhance the successful implementation of public mental health services are best when they are centrally facilitated from a locally directed, bottom-up approach (Rock, Combrinck, & Groves, 2001). From both a service delivery and administrative perspective, a bottom-up strategy has its advantages. One obvious benefit is that it requires local stakeholders to articulate objective and verifiable goals that use a “common currency” (p. 44) or terminology (Rock et al., 2001).

Similarly, MHFs have the advantage of serving as community leaders developing “upstream” versus “downstream” care, as well as providing important links to professional mental health care (Hinkle, Kutcher, & Chehil, 2006; Hoff et al., 2009; McKinlay, 1990). MHFs working in communities apply primary prevention principles by anticipating mental health services for people who may be vulnerable. For instance, MHFs in Bhutan provide drop-in peer assistance for young people challenged by rapid changes in their society. When MHF services are available at the secondary prevention level, people with mental health issues can often avoid disruptive and costly hospitalization. MHFs can assist with reducing long-term disabling effects among people recovering from a mental disorder by applying tertiary prevention measures from the bottom up (Hinkle & Saxena, 2006; Hoff et al., 2009). Furthermore, governmental direction from the top needs to intersect with community efforts from the bottom (Isaac, 2013; see Figure 1); and once programs are vetted from the top, they need to be diverted to bottom-up management (Eaton, 2013).

Although community mental health programs may achieve local success, few have been systematically scaled up to serve the needs of national populations. Despite the array of treatments for mental health, little evidence exists regarding their feasibility and effectiveness when integrated into routine care settings among low- and middle-income countries. Even though bottom-up approaches offer advantages, they also require outcome measurements, something that mental health workers have found traditionally burdensome (Rock et al., 2001). For example, evidence-based mental health interventions for people exposed to conflict and other disasters are weak, especially for strategies implemented in the midst of emergencies (Patel, Araya, et al., 2007). Only a small fraction of the clinical research trials regarding mental health treatment have been administered in low-income countries, resulting in a dearth of knowledge about treatment effectiveness in poor, culturally diverse settings (Becker & Kleinmen, 2013). Consequently, the MHF process is currently undergoing an evaluation in two diverse countries on two separate continents to seek evidence for the effectiveness of this training program. This is a critical step in the program’s continued development, because empirical evaluation of lay health workers’ implementation of community mental health services in low- and middle-income countries has been historically insufficient (Lewin et al., 2005). However, if the global strategy is only to collect more information and add to data resources, there will continue to be a gap in human resources.

As planned, individuals seeking MHF training have represented a broad cross section of local society, ranging from school teachers and principals to business owners, clergy and neighborhood workers. MHF volunteers are also police officers, neighborhood workers, community leaders, NGO employees, elders and indigenous healers. In fact, such healers in Malawi, Africa have learned to apply their first-contact mental health skills to identify, assess, support and refer people in need of acute mental health care through the MHF program. This diversity of trainee backgrounds at the grassroots level increases possibilities for addressing as many gaps as possible in community mental health care. Indeed, grassroots efforts emanate from the ground level (Eaton, 2013; Hinkle, 2010b, 2012a; Hinkle & Schweiger, 2012; Schweiger & Hinkle, 2013).

The Global MHF Partnership

Partnerships among NGOs, governments, agencies and academia can make a difference in the mental health workforce capacity by integrating global expertise with local knowledge (Fricchione, Borba, Alem, Shibre, Carney, & Henderson, 2012; WHO, 2009). As countries recognize the dearth of community health services and attempt to develop fundamental services with a mental health focus, the MHF training program is appealing because of its emphasis at the “street” or “trenches” level (Hinkle, 2012a). This is a critical component of the MHF training program since local stakeholders always have more at stake in risk reduction and capacity building than agencies outside the local neighborhood, village or barrio (Abarquez & Murshed, 2004). For example, MHF training has benefited the people of Mexico City, who have had historically limited access to mental health services (Suck, Kleinberg, & Hinkle, 2013a).

The initial stage of the MHF training process identifies local partners who have the willingness and ability to increase local mental health care capacity. NBCC-I negotiates MHF training with partners such as educational institutions, government agencies, NGOs, private companies or other entities capable of managing a training. An ideal global partner has the capacity and ability to maintain the MHF program and promote continuing mental health education. NBCC-I and respective training partners identify master trainers who can train more trainers, ensuring a multiplier effect (NBCC-I, 2013). In countries where English is not a primary or spoken language, it is necessary to translate and adapt the MHF curriculum and materials. Thus far, MHF partnerships have resulted in the curriculum being translated into 10 languages:Arabic, Bahasa Malaysian, Bhutanese [Dzongka], Chinese, German, Greek, Japanese, Portuguese, Spanish and Swahili.

The MHF Curriculum: General Features

NBCC-I has responded to the care-need gap challenge, and developed and standardized the MHF curriculum drawing on a variety of competencies derived from related mental health disciplines within a cultural context. General, nonclinical, first-responder forms of community mental health care such as basic assessment, social support and referral are included in the MHF curriculum. Similar models that include assessment, advising, agreement on goals, interventions, support and follow-up have been used successfully in mental health care (Fiore et al., 2000; Hinkle, 2012b, 2012c; Whitlock, Orleans, Pender, & Allan, 2002). Currently there are MHFs on five continents, with new trainings being coordinated almost weekly. In developing the curriculum, an eclectic group of professional contributors allowed for a flexible training model with expertise drawn from various international practices. The training consists of 30 hours that can be taught on consecutive days, or divided into its 20 modules and taught over several weeks, depending on the needs of the local community (Hinkle & Henderson, 2007). As local stakeholders are identified and trained using the MHF curriculum, they become the foundation on which to build community mental health care.

The MHF training includes a certificate of completion for anyone successfully completing the program, and additional certificates of completion for trainers and master trainers. Trainers are required to hold a bachelor’s degree or its equivalent, and master trainers must have a master’s degree or its equivalent in a mental health–related discipline. One affirming by-product of the training is the identification of individuals who desire more training and education in mental health services. For example, the MHF program in Bhutan has led to specified substance abuse training in several communities, as well as two students seeking graduate studies in counseling in the United States.

Specific Features of the MHF Curriculum

The MHF curriculum is based on the universality of mental stress, distress and disorders (Desjarlais, Eisenberg, Good, & Kleinman, 1995; Hinkle & Henderson, 2007). MHF training includes numerous topics such as basic helping skills, coping with stress, and community mental health services. The program consists of fundamental, integrated mental health knowledge and skills ranging from community advocacy and commitment, to specified interventions such as suicide mitigation. Also included in the curriculum are segments on working with integrity and not providing services outside the limits of training and experience (Hinkle, 2010a; Reyes & Elhai, 2004). In general, MHFs are taught that negative and unhealthy assumptions about life and living contribute to additional mental and emotional stress (Browne & Winkelman, 2007; Feiring, Taska, & Chen, 2002; Sonne, 2012).

More specifically, the curriculum begins with a section on the benefits of investing in mental health, cost-effective interventions, impacts of mental disorders on families, barriers to mental health care, confidentiality and privacy, and the goals of the MHF program. Understanding perspectives regarding human feelings, effective nonverbal and verbal communication, and using questions effectively in the helping process also are covered in the curriculum, as well as how to assess problems, identify mental health issues, and provide support (Hinkle & Henderson, 2007). Making effective referrals is a crucial segment of the curriculum because this skill also serves the purpose of steering people to physicians for co-occurring physical disorders such as diabetes, heart disease and chronic pain (Gureje, 2013).

MHF trainees also learn how to effectively end a helping relationship—an essential skill taught to mental health workers for the past 40 years (Hines, 1970; Hinkle & Henderson, 2007). MHFs learn that the helping process involves joining with the person seeking assistance, identifying specific concerns, assessing the level of difficulty, surveying the possibilities, solving problems and making choices, and referring to more formal care where appropriate. This is accomplished within a simple framework emphasizing personal strengths and mitigation of significant stress.

Following the basic helping skills section of the curriculum, which emphasizes the age-old but important phenomena of human development and diversity, trainees concentrate on the abilities, needs and preferences that all people possess and how these are integrated in various cultures (Elder & Shanahan, 2007; Huston & Bentley, 2010; Lerner, 2007). A section on understanding various types of encountered problems introduces trainees to the concept of a balanced, less balanced, little balanced, or off balance mental health continuum, alongside how to solve problems and set goals with people experiencing difficulty coping with life (Hinkle & Henderson, 2007). Similarly, trainees learn about stress, distress and basic mental disorders including anxiety and post-traumatic stress disorder (PTSD), depression and mania, psychosis and schizophrenia, substance abuse and dependence, delirium and dementia, mental retardation (intellectual disability), chronic pain, and epilepsy. Child reactions to trauma (van Wesel, Boeije, Alisic, & Drost, 2012) and child maltreatment (Wekerle, 2011) also are covered in the MHF curriculum, which emphasizes helping children and adolescents in the least restrictive environment and as close to their communities as possible (Hinkle & Henderson, 2007).

Preventing suicide and effectively dealing with an actual suicide are two topics of relevance covered in MHF training. Suicide is a leading cause of death in low- and middle-income countries, especially among young people (WHO, 2006a). Self-poisoning using pesticides is common, with estimates of 300,000 of these deaths a year in the Asia-Pacific region alone (Patel, Araya, et al., 2007), validating the need for suicide’s inclusion in the curriculum.

In the 1990s, humanitarian organizations began to recognize the increased need for psychosocial support after various types of disasters (Barron, 2004; Wells, 2006). Disasters result in tremendous loss of property, resources and life. In addition, political, economic and social disruptions are common consequences that have mental health–related implications. Therefore, information about assisting individuals and families in the aftermath of disasters is included in the MHF curriculum (Hinkle & Henderson, 2007; Wells, 2006). The MHF training also emphasizes ways to assist with situations involving domestic violence, refugees, migrants and victims of human trafficking and war, as well as other unfortunate forms of crisis.

Stress-related disorders, as depicted in the MHF curriculum, go largely untreated in many areas of the world, especially when crises and disasters strike. It is all too often the scenario that an earthquake, typhoon, hurricane or human-made crisis has occurred, and limited or no mental health care services are available following the event. Attempts to provide assistance in the aftermath of these disasters have come from governmental responses, NGOs, and community and religious organizations, but it is important to note that even professional mental health workers receive cursory instruction in disaster interventions (Hinkle, 2010a). The need for greater mental health response services is apparent; MHFs from Lebanon to Liberia have assisted communities following civil war and refugee crises, and MHFs in China have assisted in the aftermath of a major earthquake using the basic mental health training they received from the MHF curriculum.

Regardless of their genesis, many mental health–related concerns are largely dependent on problem-solving abilities, a focus on cultural values regarding mental health functioning, and social and economic support (Hinkle et al., 2006; Hoff et al., 2009), all of which are addressed in the MHF curriculum. Studies from stress-related literature suggest that a fundamental problem-solving coping approach is generally associated with positive outcomes (Benight, 2012; Taylor & Stanton, 2007), whereas avoidant-related coping is associated with negative outcomes (Littleton, Horsley, John, & Nelson, 2007); thus the emphasis on problem-solving skills in the MHF curriculum.

Lastly, consulting with helping professionals during mental health emergencies and recognizing the importance of self-care when working in crisis situations also are part of the MHF curriculum. The curriculum culminates with the all-important local contextualizing of what trainees have learned during their MHF training (Hinkle & Henderson, 2007; Sonne, 2012).

Potential Limitations

Unfortunately, organizational, cultural, and professional concerns coinciding with the often ambiguous role and purpose of mental health care can beset the expanding use of community helpers and may have an unintended impact on role identities among the general health workforce (see Warne & McAndrew, 2004). Possibly complicating matters further, the MHF program is a set of concepts and skills, not a professional designation. One concern associated with the MHF program is therefore its potential for propagating invisibly and resulting in new worker roles that cause confusion within standardized health care. Although “the potential of the fully visible and verbal paraprofessional to effect changes in the delivery of psychiatric care is vast” (Lynch & Gardner, 1970, p. 1478), it could become problematic in some locations if MHFs are not strategically blended into community health services. It has long been known that without a viable, transparent strategy, the utilization of MHFs could make for strained relationships in places where the program is not fully vetted. Furthermore, organizational structures that are not flexible or willing to pursue institutional change and innovation may have more difficulty accepting the MHF program (Hinkle, 2012b). Therefore, local and global political and networking skills are critical to the MHF program’s sustainability.

Working conditions and available remuneration for community programs and workers raises several questions that will need to be addressed at some point (Hongoro & McPake, 2004). For instance, could municipalities and governments make MHF a job classification with an upwardly mobile career ladder within existing mental health services? Where financial incentives are not possible, could ad hoc benefits such as access to more training be feasible? How will MHF trainings be sustained in communities over time? Will volunteers be able to conduct the MHF program with limited resources? Additionally, for the program to be sustainable, trainers must have incentives to train more MHFs as community service providers. Without trainers teaching more programs, it is likely that a multiplier strategy will have limited success.

Another potential criticism of the MHF program is that the quality and safety of care could be compromised using community workers. However, the more critical point remains that providing basic assistance is much safer and salubrious than providing no care at all (see Hongoro & McPake, 2004). As in mental health nursing, supervision and mentoring of MHFs will at some point become an issue (Eaton, 2013; Warne & McAndrew, 2004). Furthermore, supportive supervisory relationships are important because supervisors are perceived as role models (Thigpen, 1979) in addition to providing needed guidance for informal community mental health workers.

Future MHF training strategies will need to incorporate continuing community educational development in mental health. Twinning or pairing universities in developing countries with those in less-developed countries is one method for increasing continuing education efforts. Distance learning can be an effective delivery method as well. However, twinning and distance education are all too often not core interests in developing nations, which tend to lack expertise in managing such partnerships (see Fricchione et al., 2012; Hongoro & McPake, 2004).


For the MHF program to proliferate, it will take not only training, education and implementation in often less than optimal working conditions, but also savvy negotiation of often poorly managed political systems that experience some level of corruption and inability to impact the universal stigma that plagues mental illness. To manage the program effectively, the global MHF strategy will need to continue to be accessible from the bottom up and maintain an uncomplicated implementation process. Patel (2013) has advocated that community mental health must be simplified, available where people live, locally contextualized, affordable and sustainable. The MHF program has met all of these criteria with the exception of sustainability, and only more time will tell the level of program longevity.

Advances in alleviating the costs of mental disorders have been limited and slow in coming (Becker & Kleinman, 2013). It is abundantly obvious that the challenges of unmet mental health needs negatively impact societies and economies around the globe. Becker and Kleinman (2013) have recently reported that “according to virtually any metric, grave concern is warranted with regard to the high global burden of mental disorders, the associated intransigent, unmet needs, and the unacceptable toll of human suffering” (p. 71). The burden of mental disorders at the social and individual level is comparable to that of physical disorders and substantially impacts the capital of all countries. Social factors are critical to the promotion and prevention of mental health (GGMHP, 2013b). Furthermore, children exposed to adult mental health disorders among their caregivers, as well as emotional psychological trauma, are predicted to have higher risks of mental disorders in adulthood, further compounding the problem (Chatterji, He, & Alonso, 2013; Patel, Araya, et al., 2007; Patel, Flisher, Hetrick, & McGorry, 2007). WHO (2010a, 2010b) has recommended bridging the care-need gap; however, this will not occur while services are embedded in professional silos rather than being population-centered (Chatterji & Alonso, 2013; Hinkle, 2012c).

The need to address workforce issues affects the quality and quantity of international mental health services (Warne & McAndrew, 2004); there is a clear link between human resources and population health. Community and family caregiving for mental disorders, often uncompensated, has a “tremendous value from a public health perspective by way of offsetting the costs and services of expensive and critically shorthanded healthcare professionals” (Viana et al., 2013, p. 134). At the American Psychiatric Association’s annual convention in 2013, Galea reported that the social aspects of mental health are not a sideshow, but at the very core and not being paid attention to. Unfortunately, not even the laudable efforts of the WHO or United Nations have been able to bring countries that are in desperate need of basic mental health care together effectively. Sadly, psychiatry alone cannot do enough in the global context; world mental health is a social issue (Galea, 2013) and much larger than any one profession (Furtos, 2013). This reality underscores the need for urgent development of grassroots community mental health programs.

For over 40 years, community mental health workers have known that a key component of any program’s design is its ability to be flexible (see Lynch & Gardner, 1970). Flexibility allows for the modification and contextualization of programs by local leaders to reflect realities of current social contexts and circumstances (Furtos, 2013; Rock et al., 2001). As aforementioned, this approach grounds the MHF program on the principle that mental health care is a combination of basic, universally applicable and context-specific knowledge and skills. Supportive social networks in the community result in less need for expensive professional treatments and hospitalizations (Forchuk et al., 2005). Moreover, grassroots approaches will aid global attempts at deinstitutionalization.

Governments of low-income countries are constrained by a lack of resources. In fact, in 85% of low-income countries, essential psychotropic medications are not available (Becker & Kleinman, 2013); monies for mental health care are disproportionately lacking even though their associated burden is tremendous (WHO, 2004a). Wider horizontal approaches to global community health care have been successful in the management of childhood illness (Gwatkin, 2004) and can likewise be successful in general mental health care. Furthermore, the benefits of essential psychotropic medications can be greatly enhanced by adjunctive psychosocial treatments including population-based models of mental health care (Patel, Araya, et al., 2007; Patel, Flisher, et al., 2007).

In summary, the MHF program is making an impact from Bhutan to Berlin and from Botswana to Bulgaria. Its training process provides equitable access to first-responder interventions including mental health promotion, advocacy, monitoring and referral, and the implementation of community MHF training furthers the development and delivery of community-based care consistent with WHO’s recommendations for addressing global mental health needs. The population-based, transdisciplinary MHF training model provides countries with a workable human resource development strategy to effectively and equitably bridge the mental health need-care service gap, one country at a time.


Conflict of Interest and Funding Disclosure

The author reported no conflict of interest or funding contributions for the development of this manuscript.




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Dr. J. Scott Hinkle is the Director of Professional Development at NBCC-I. For further information on the MHF program, please contact Adriana Petrini at petrini@nbcc.org. The author appreciates editorial contributions from Laura Jones, Katherine Clark, Ryan Vale, Traci Collins, Allison Jones, and Keith Jones. A version of this article was originally presented at the World Mental Health Congress, August 28, 2013, Buenos Aires, Argentina (Spanish: “Facilitación de Salud Mental (MHF): Una Estrategia Comunal”). Correspondence can be addressed to J. Scott Hinkle, NBCC, 3 Terrace Way, Greensboro, NC 27403, hinkle@nbcc.org.

Counselors Abroad: Outcomes of an International Counseling Institute in Ireland

Lorraine J. Guth, Garrett McAuliffe, Megan Michalak

As the counseling profession continues to build an international community, the need to examine cultural competence training also increases. This quantitative study examined the impact of the Diversity and Counseling Institute in Ireland (DCII) on participants’ multicultural counseling competencies. Two instruments were utilized to examine participants’ cross-cultural competence before and after the study abroad institute. Results indicated that after the institute experience, participants perceived themselves to be more culturally competent, knowledgeable about the Irish culture, skilled in working with clients from Ireland, and aware of cultural similarities and differences. Implications for counselor education and supervision, and future research also are outlined.

Keywords: study abroad, multicultural competencies, cross-cultural competence, international, counselor education  and supervision, Ireland

The standards set by the Council for Accreditation of Counseling and Related Educational Programs (CACREP; 2009) require programs to provide curricular and experiential opportunities in social and cultural diversity. Specifically, CACREP requires counseling curricula to incorporate diversity training that includes “multicultural and pluralistic trends, including characteristics and concerns within and among diverse groups nationally and internationally” (CACREP, 2009, Section II, Code G2a; p. 10). Endorsement of diversity training by the counselor education accrediting body underscores its importance in counselor training; therefore, counselors-in-training must be provided opportunities to be culturally responsive in their work with clients (McAuliffe & Associates, 2013; Sue & Sue, 2012).

This cultural responsiveness is particularly important given the globalization of the counseling movement and the need for counselors to become globally literate (Hohenshil, Amundson, & Niles, 2013; Lee, 2012). However, counselor education training programs have fostered this multicultural competence with students in myriad ways (Lee, Blando, Mizelle, & Orozco, 2007). For example, multicultural courses have often focused on developing trainees’ cross-cultural competencies in the three broad areas of awareness of their own cultural values and biases; knowledge of others’ customs, expectations, and worldviews; and culturally appropriate intervention skills and strategies (Sue, Arredondo, & McDavis, 1992).

A body of literature has examined the progress of educational programs in incorporating these aspects of diversity into the curricula. For example, Díaz-Lázaro and Cohen (2001) conducted a study that explored the impact of one specific course in multicultural counseling. They found that cross-cultural contact, such as with guest speakers, helped students develop multicultural knowledge and skills; however, they found no indication that the course impacted students’ self-awareness. Guth and McDonnell (2006) examined counseling students’ perceptions of multicultural and diversity training. Courses were found to contribute somewhat to students’ knowledge, but the study found that students gained greater knowledge from personal interactions among peers, interactions with faculty, and other experiential activities outside of coursework. Additional research has shown that multicultural training is significantly related to multicultural competence (Castillo, Brossart, Reyes, Conoley, & Phoummarath, 2007; D’Andrea, Daniels, & Heck, 1991; Dickson, Argus-Calvo, & Tafoya, 2010). A clear message from the literature highlights the importance of personal cross-cultural contact in culturally responsive counseling.

This previous research was limited in that the authors examined only the impact of training offered in the United States, leaving out the potential added value of personal cross-cultural experiences in an international context. Given the impact of direct cross-cultural experiences, a study abroad experience for counselor trainees might be a powerful way to deepen cultural understanding and responsiveness. This quantitative study was designed to examine the outcomes of this counselor trainee study abroad institute on participants’ perceptions of their multicultural competence.


Research on Study Abroad Experiences


Study abroad programs are not commonly rigorously researched because “program evaluation is an afterthought to an ongoing program undertaken by extremely busy program administrators” (Hadis, 2005, p. 5). Although data regarding study abroad experiences are primarily anecdotal, the literature does suggest several positive outcomes of a study abroad institute including personal development, intellectual growth and increased global-mindedness (Carlson, Burn, Useem, & Yachimowicz, 1991). Short-term study abroad experiences also were found to produce positive changes in cultural adaptability in students (Mapp, 2012). However, most of the study abroad research has been conducted in disciplines other than counseling, such as business (Black & Duhon, 2006), nursing (Inglis, Rolls, & Kristy, 1998), and language acquisition (Davidson, 2007). Furthermore, the research has mainly focused on the experiences of undergraduate university students and has not examined the experiences of graduate trainees (Drews & Meyer, 1996).

Several studies have been conducted that are relevant to the counseling profession. Kim (2012) surveyed undergraduate and graduate social work students and found that study abroad experiences are a significant predictor of multicultural counseling competency. Jurgens and McAuliffe (2004) also conducted a study that explored the impact of a short-term study abroad experience in Ireland on graduate counseling student participants. The results indicated that this program was helpful in increasing students’ knowledge of Ireland’s culture, largely due to experiential learning and personal interactions. The current study expands on Jurgens and McAuliffe’s research (2004) by further examining the impact of a counseling and diversity institute that was offered in Ireland. The primary research questions for this quantitative study were as follows: (1) Did the study institute have an impact on participants’ multicultural counseling competencies? (2) Did this study institute have an impact on participants’ multicultural counseling competencies in working with individuals who are Irish?





Twenty (87%) graduate counseling students and three (13%) professional counselors voluntarily participated in this research study while attending the DCII in Ireland. The sample consisted of 83% women and 17% men; 82% identified themselves as Caucasian/European American, 9% as African American, and 9% did not identify their race. The mean age for the sample was 32 (range: 22–60 years). Regarding sexual orientation, 91% of the participants indicated they were heterosexual; 4% indicated they were gay; and 4% indicated they were bisexual. Regarding disability status, 87% of the participants reported not having a disability, 9% indicated they had a disability, and 4% did not answer the question.



The study assessed participants’ cross-cultural counseling competence with the Cross-Cultural Counseling Inventory-Revised (CCCI-R, LaFromboise, Coleman, & Hernandez, 1991). The CCCI-R is a 20-item instrument initially created so that supervisors could evaluate their supervisees’ cross-cultural counseling competence. Questions on this instrument are rated on a 6-point Likert-type scale (1 = strongly disagree; 6 = strongly agree). The scale has been found to have high internal consistency and reliability, and high content validity (LaFromboise et al., 1991). Another “recommended use of the CCCI-R is as a tool for self-evaluation” (LaFromboise et al., 1991, p. 387). Therefore, the CCCI-R was slightly modified so that participants could rate themselves to understand perceptions of their own cultural competence, rather than rate other counselors on their cultural competence. Higher scores on this instrument indicate an individual’s belief that he or she has greater cultural competence. Sample prompts include the following: “I am aware of my own cultural heritage,” “I demonstrate knowledge about clients’ cultures,” and “I send messages that are appropriate to the communication of clients.” In the present study, Cronbach’s alpha was used to assess the internal consistency of the CCCI-R and it was reliable at both times of measurement (pretest = .91; posttest = .93).

Four additional Likert-type items were added to the pretest and posttest questionnaires, which asked participants to rate their multicultural awareness, knowledge, and skills related to the Irish culture. The items included were as follows: (1) I am knowledgeable of the culture of Ireland; (2) I possess the skills in working with a client from Ireland; (3) I am aware of the differences between the Irish culture and my own culture; and (4) I am aware of the similarities within the Irish culture and my own culture. Participants rated the extent to which they agreed with each item from 1 (strongly disagree) to 6 (strongly agree). Because of the significant (p < .01) correlation among these four items, a single variable was established called Ireland Multicultural Counseling Competencies Scale (IMCCS). In the present study, Cronbach’s alpha was used to assess the internal consistency of the IMCCS, which was reliable at both times of measurement (pretest = .88; posttest = .90).



At the beginning of the study abroad institute, participants completed a pretest questionnaire that contained a demographic information form, the CCCI-R, and the IMCCS. Participants then participated in the two-week study abroad institute. At the conclusion of the institute, participants completed a posttest questionnaire that contained the CCCI-R and the IMCCS.


Diversity and Counseling Institute in Ireland. Study abroad institutes offered in the counseling profession can further counselors’ multicultural competence by immersing trainees in a non-American culture for a period of time. With that intent, the two-week DCII was created to increase participants’ cultural awareness, knowledge and responsiveness. The goals of the DCII were to increase participants’ (1) awareness of their own cultural background and values; (2) knowledge of the American, Irish, and British cultural perspectives; and (3) knowledge of culturally appropriate counseling strategies. Participants learned about the counseling profession in Ireland from leaders in the Irish mental health field; studied core multicultural issues with nationally known U.S. counseling faculty; were immersed in the Irish culture through tours, lectures, and informal experiences; and visited Irish counseling agencies and social programs.




A t-test was performed to examine differences between participants’ CCCI-R mean score across time from pretest to posttest (see Table 1 for mean differences and standard deviations). There were significant differences (p < .0001) in participants’ overall scores on the CCCI-R after they attended the DCII in Ireland, indicating that participants perceived themselves to be more culturally competent by the end of the study abroad experience.

A t-test also was utilized to examine differences between participants’ IMCCS mean score across time (see Table 1 for the mean difference and standard deviations). There were significant differences (p < .0001) in participants’ overall scores on the IMCCS after attending the DCII in Ireland. Thus, participants thought they were more knowledgeable about the culture of Ireland, possessed more skills in working with clients from Ireland, had an increased awareness of differences between the Irish culture and their own, and had an increased awareness of similarities between the Irish culture and their own.


Table 1

Mean Difference between Participants’ Pre- and Post-Institute Multicultural Competence Scores





Regarding the under-researched topic of intentional study abroad counselor education experiences, this study indicated that such an experience can have a positive impact on counselors’ multicultural competency. Previous research on non-counseling study abroad opportunities found that participants experienced personal development, intellectual growth and increased global-mindedness (Carlson et al., 1991). This study begins to address whether a counseling international experience has an effect on counselor multicultural competency.

International study abroad experiences can affect individuals’ perspectives on other cultures, as well as on their own. In the case of this research, participants reported an increase in their cultural competence after the intentional study abroad counselor education experience. These results confirm previous social work research that found a positive relationship between studying abroad and multicultural competencies (Kim, 2012). Further research should explore what components of this institute in particular influenced participants’ multicultural awareness, knowledge and skills.

The overall multicultural counseling competency improvement demonstrated in this study is encouraging. It is important to note that the institute included both experiences and conceptual material. The learning was perhaps enhanced by the experiential learning theory model used to design the institute (Kolb & Kolb, 2009). In this study abroad institute, experiences included visits to specific counseling and educational programs. Participants then reflected on those experiences through journaling and large group processing. Counselor educators might pursue such international initiatives to trigger counselor cultural self-awareness, increase knowledge of other cultures, and build culturally responsive counseling skills.

Study abroad for counselors might be seen as a “value-added” learning opportunity. While at-home multicultural counselor education has been studied (Cates, Schaefle, Smaby, Maddux, & LeBeauf, 2007; Zalaquett, Foley, Tillotson, Dinsmore, & Hof, 2008), such learning may be enhanced by the experience of being immersed in a foreign culture (Kim, 2012). Prolonged immersion in another culture allows counselors-in-training to gain a more nuanced understanding of the differences and similarities among cultures. Participants reported being more aware than before of differences and similarities between the Irish culture and their own culture. Although not all immersion opportunities happen internationally, the degree to which these participants were immersed was novel and led to a significant increase in culturally relevant knowledge, skills and awareness. The degree to which immersion experiences are effective should continue to be explored within the counseling profession.

Transferability of the learning from study abroad is of course crucial, as it would be insufficient to merely learn the particulars of another counseling culture. In that sense, the overall dislocation of being in a foreign culture may transfer to an increase in trainees’ empathy for members of non-dominant cultures in their homelands. It would be difficult to simulate such experiences in the domestic environment. Thus, when designing training experiences, educators could consider the impact of experiential training experiences outside of the home country. While planning these experiences are logistically challenging, the payoff can be impactful (Shupe, 2013).

International study abroad institutes have implications for the counseling community at large. As the profession continues to construct a professional identity and establish its role in the mental health community, counselors must consider the counseling profession as a whole, not solely the parts of the profession within the cultural worldview. Incorporating international experiences into the training practice allows more counselors to communicate and connect as a whole, in order to best develop and advocate for the counseling profession. Furthermore, collaborating with counselors internationally provides counselors-in-training the opportunity to increase their cultural self-awareness, as well as allows counselor educators to examine current training practices and their effectiveness. This assessment may take place through direct observation of international training practices, or more covertly in reflecting on the components of the institute that appeared to impact students.

The results of this study need to be examined in light of several limitations. First, this pre-post design only examined the impact of this study abroad institute. Future research could compare study abroad experiences to other training methods. Future research also could disaggregate the factors that actually contributed to positive outcomes, by investigating the relative contribution of informal encounters, lectures on Irish counseling and social issues, general seminars on culturally alert counseling, and other experiences in the study abroad program. Second, participants volunteered to be part of this study and were predominantly Caucasian/European American and heterosexual women. Future research could seek to replicate these results, using a control group and a more diverse, randomly selected group of participants. Finally, the focus of this research was the impact of a DCII in Ireland. Future research could explore the impact of counseling study abroad programs in other countries. Long term follow-up measures also could be utilized to see if the positive changes in multicultural counseling competencies remain stable over time.




This study was designed to examine the impact of the diversity and counseling study abroad program in Ireland on participants’ multicultural competencies. The results indicate that the study abroad experience in Ireland enhanced participants’ multicultural counseling competencies. These results provide beginning data regarding the benefits of this type of study abroad diversity training and encourage counselor educators to pursue and evaluate such experiences.



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Lorraine J. Guth, NCC, is a Professor and Clinical Coordinator at Indiana University of Pennsylvania. Garrett McAuliffe is a Professor at Old Dominion University. Megan Michalak, NCC, is an Assistant Professor at Antioch University New England. Correspondence can be addressed to Lorraine J. Guth, IUP Department of Counseling, 206 Stouffer Hall, Indiana, PA 15705, lguth@iup.edu.

Professional Identity of Counselors in Mexico: A Commentary

Viviana Demichelis Machorro, Antonio Tena Suck

The authors conducted an exploratory study using cultural domain analysis to better understand the meaning that advanced students and professional counselors in Mexico give to their professional identity. More similarities than differences were found in the way students and professionals define themselves. The most relevant concepts were empathy, ethics, commitment, versatility, training and support. Students gave more weight to multiculturalism and diversity, whereas professionals prioritized commitment and responsibility at work. Prevention did not appear as a relevant concept, posing challenges for professional counselor training programs in Mexico.

Keywords: professional identity, multiculturalism, ethics, prevention, counselor training, Mexico

In the field of professional counseling, it is important to consider the benefit of developing a strong professional identity. Initiative 20/20: Vision for Counseling’s Future, represented by influential organizations such as the American Counseling Association (ACA), the Council for Accreditation of Counseling and Related Educational Programs (CACREP), and the National Board for Certified Counselors (NBCC), identifies principles that must be developed in order to strengthen the counseling profession (ACA, n.d.). These principles include sharing a common professional identity and presenting the counseling profession in a unified way. CACREP (2009) recognizes the relevance of promoting professional development in counseling programs; the organization’s standards were written to ensure that counseling student development is congruent with professional identity, as well as the necessary knowledge and skills to practice counseling effectively and efficiently.

In Mexico, steps have been taken toward developing such standards. The Mexican Association for Counseling and Psychotherapy (AMOPP), founded in 2008, has stated in its mission and objectives the promotion of counselor identity and stimulation of professional development (AMOPP, 2014). However, the process of defining professional identity for counselors has complex aspects that imply a great challenge for the Mexican counseling guild (Calva & Jiménez, 2005; Portal, Suck, & Hinkle, 2010).

First, there are few Mexican university programs that train counselors. The only such Mexican graduate program is the master in counseling (maestría en orientación psicológica) at Universidad Iberoamericana, which started in fall 2003 and was awarded CACREP accreditation in 2009. This program prepares students in prevention, evaluation and intervention using an integrative approach that includes theories and techniques, promotion of multicultural sensibility, and a focus on vulnerable populations (Universidad Iberoamericana, n.d.-a). Most students in this master in counseling program have a bachelor’s degree in psychology, which makes for a mixed psychologist/counselor identity that is not easy to separate, and that is likely experienced as a psychological specialty by faculty, students and the general public.

In contrast to countries like the United States and Canada, where a bachelor’s degree is awarded first and students professionalize afterward at the graduate level, in Mexico, students professionalize at the undergraduate level, which promotes professional identity at this point. Thus, in Mexico the possibility of studying for an undergraduate professional program in counseling does not exist, which contributes to the difficulty of counseling being recognized as an independent profession.

There are plenty of reasons to study the professional identity of counselors in Mexico. First, counseling awareness within the community could be increased, making counseling accessible to a population that needs quality mental health services. The Mexican Poll of Psychiatric Epidemiology (ENEP) of the National Institute of Psychiatry reveals that 28.6% of the population presents some type of psychiatric disorder at some point in life, mostly anxiety (14.3%), followed by the use of illegal substances (9.2%) and affective disorders (9.1%). Nevertheless, despite this high incidence of mental health problems, only 10% of the population that presents with a mental disorder receives the attention it needs (Medina-Mora et al., 2003).

Secondly, there is limited professional literature in Mexico regarding professional counseling. Searching behavioral science databases revealed only one reference in a Mexican book regarding psychologists’ professional identity (Harsh, 1994) and no articles about counselors’ professional identity. If the professional identity of counselors in Mexico were more defined, it could help prospective students who are interested in studying counseling. It also could help practicing counselors form a solid base to serve as a platform to strengthen and enrich their professional behavior and clarify their professional identity. Neukrug (2007) has stated that when counselors find out who they are, they will know their limits and relationships with other professions. Therefore, the authors explored the professional identity of counselors in Mexico to better understand their definitive characteristics.

Professional identity, according to Balduzzi and Corrado (2010), is the definition one makes about self in relation to work and an occupational guild. It begins with training, during which professional identity can be promoted or obstructed, and includes interactions with others as well as modeling. Counselors begin to develop professional identity as they are trained (Auxier, Hughes, & Kline, 2003; Brott & Myers, 1999), integrating personal characteristics in the context of a professional community (Nugent & Jones, 2009). Brott and Myers (1999) studied how professional identity is developed among school counseling graduate students in the United States and reported that counselors develop an identity that serves as a reference for professional decisions and assumed roles. These researchers used grounded theory to explain the identity development process of counselors in training. First, students go through a stage of dependence to attain the stage of independence at which the locus of control is internal and the counseling student has the opportunity for self-evaluation without external evaluation. In this advanced stage, experience is integrated with theory, joining personal and professional identities.

To analyze the development of professional identity in counseling students in the United States, Auxier et al. (2003) developed their research from a constructivist model that assumed reality is socially developed, determined by the place where it is elaborated and based on the participants’ experience. They developed the model of “recycling identity formation processes” (p. 32). This model explains that for constructing an identity, a person needs to go through (a) conceptual learning via classes and lectures; (b) experiential learning by practices, dynamics and internship; and (c) external evaluation from teachers, supervisors, coworkers and clients.

Nelson and Jackson (2003) wanted to better understand the development of professional identity among Hispanic counseling students in the United States. They conducted a qualitative study and found seven relevant topics: knowledge, personal growth, experience, relationships, achievements, costs, and perceptions of the counseling profession (Nelson & Jackson, 2003). Although the results were congruent with other findings, such as the need to be accepted and included, relationships such as those available from caring faculty or the support of family and friends were identified as meaningful factors that contribute to formation of a professional identity.

Similarly, du Preez and Roos (2008) used social constructivism to analyze the development of professional identity in South African students between the fourth and last year of their studies as undergraduate counselors. Participants elaborated on visual and written projects regarding their professional development training. Through an analysis of this work, four professional identity themes were identified: capacity for uncertainty, greater self-knowledge, self-reflection and growth (du Preez & Roos, 2008).

Skovholt and Ronnestad (1992) explained that identity development implies progress of attitudes about responsibility, ethical standards, and membership in professional associations. According to the Skovholt and Ronnestad (1992), a counselor’s identity differs from other professional identities because a therapeutic self is shaped by a mixture of professional and personal development. The researchers explained that professional identity is a combination of professional self (e.g., roles, decisions, applying ethics) and personal self (e.g., values, morals, perceptions) that create frameworks for decision making, problem-solving patterns, attitudes toward responsibilities, and professional ethics.

In one of the few quantitative investigations on the topic, Yu, Lee and Lee (2007) used the concept of “collective self-esteem” (p. 163) as a synonym for collective and professional identity. They conducted a study to learn whether the collective self-esteem of counselors influences or mediates their work satisfaction and how they relate to clients. The researchers found that “job  dissatisfaction is negatively related to greater levels of private collective self-esteem, and in turn, greater private collective self-esteem is positively related to better client relationships” (p. 170). Based on their conclusions, it is important to study the professional identity of counselors in Mexico, who must work from a place of job satisfaction and good client relationships in order to successfully address their clients’ social needs.

Hellman and Cinamon (2004) performed a series of semi-structured interviews for 15 professional school counselors with a consensual qualitative research (CQR) strategy to classify counselors through the stages of Super’s (1992) career theory: exploration, establishment, maintaining and specialization. The classification was made according to the perceptions the researchers described about counseling, professional identity, work patterns, and resources and barriers at work. In the beginning stages of their career, counselors describe school counseling as a job or a role, but later they consider counseling a profession. Furthermore, counselors start by depending on external recognition, specific techniques, and highly structured programs. As they become more experienced, counselors gain self-confidence and rely more on their professional judgment.

In general, researchers have described subjective experience to explain the development of professional identity. Furthermore, findings suggests that counselors in their identity development gain more self-knowledge, confidence in their abilities and judgment, knowledge and involvement in their profession and its standards, and a combination of personal and professional characteristics and experiences.


Cultural domain with free listing was chosen as the data collection technique. Cultural domain is “the set of concepts chosen by memory through a reconstructive process that allows participants to have an action plan as well as the subjective evaluation of the events, actions or objects, and it has gradually become one of the most powerful techniques to evaluate the meaning of concepts” (Valdez, 2010, p. 62). It has been accepted in Mexico and applied principally in social psychology and education to define and delineate several concepts such as psychologist (García-Silberman & Andrade, 1994); love, men and women (Hernández & Benítez, 2008); parenting (Medina et al., 2011); the rich and poor (Valdez, 2010); family (Andrade, 1994, 1996; Camacho & Andrade, 1992); and corruption (Avendaño & Ferreira, 1996), among others. This methodology was chosen because “professional identity” is a subjective concept to which different meanings are granted based on personal experiences; the idea was to show the concepts related to the meaning counselors give to their identity.

In this study, the authors posed the following question: What meaning do Mexican counselors give to their professional identity? The dependent variable was professional identity and the attributive variable was level of preparation (student or professional). The study was transversal (data recovery at a unique time frame) and descriptive.


The participants in the study included advanced students in at least their third semester in the master’s counseling program at Universidad Iberoamericana and professional counselors who graduated from the program at least one year ago. Fifteen of 17 advanced students (88.23%) participated, including 3 men and 12 women with an average age of 29.40 years. Twelve of 29 graduates (41%) participated, including 1 man and 11 women, with an average age of 42.75 years.

Survey Development and Procedure

Each participant was asked to list 10 words or brief terms to describe the concept counselor professional identity. Afterward, participants were asked to rank each word from 1–10, assigning 1 to the characteristic word considered the most relevant and 10 to the word considered least relevant. Advanced counseling students were given the survey in their classrooms and graduate counselors were sent the survey via e-mail. The surveys were analyzed following Valdez (2010), obtaining the definitions with the semantic weight (M), for both students and professionals, considering the frequency with which the words were mentioned, as well as the assigned rankings. The authors used a mathematical procedure called el valor M total [Total M Value] (VMT; Valdez, 2010), which entails multiplying the frequency of occurrence times the weight of each defining word. Next, a cross-multiplication was done, considering the highest VMT as 100% in order to obtain the semantic distance between each concept and the stimulus concept (i.e., counselor professional identity). This procedure is referred to as FMG (Valdez, 2010).


For the students, the defining terms for the stimulus counselor professional identity, listed in the order of the frequency and relevance with which the participants used and ranked them, were as follows:

empathic, understands, sensitive, ethical, honest, sincerity, fair, prepared, knowledge, trained, updated, flexible, adapts, support, help, backup, listening, human, warm, congruence, authentic, mental health, well-being, trustable, integrative, responsible, commitment, intervening, implementing, action, professionalism, respect, tolerance, multicultural, contextualized, diversity, observer, acceptance, non-judgment, structure, organizes, collaboration, design, planning, creativity, patience, goal recognition, positive view, growth, development, contention, service attitude, dedication, different, brief, social commitment, interdisciplinary, reflective, analyzes, guides, communicates, open, wide view, curious, scientific, relationship, psychotherapist, therapist, educates, prudent, diagnoses, prevention, dynamic, specialized, assertive, personal, practical, resilient, facilitator, personal therapy, strategic and consultant.

Consensually, the researchers separated these concepts into semantic categories, taking into account terms that are synonyms or that have a very similar meaning, leaving 57 definitions. Similarly, those concepts with more semantic weight were detected, resulting in the Semantic Association Memory (SAM) group according to Valdez (2010), which refers to the 15 categories with the most relevance (M total). This process is done considering frequency and weight. This group includes 17 categories since the last 3 present the same value. Table 1 shows terms that counseling students used to define counselor identity, weighted in order of relevance.

Table 1

Counseling Students’ Identity


For graduated professional counselors, the defining terms for the stimulus counselor professional identity, listed in the order of frequency with which participants used and ranked them, were as follows:

empathic, commitment, dedicated, responsible, ethical, serves vulnerable populations, social service, prepared, experienced, updated, supervised, studious, research, listening, authentic, genuine, congruent, support, assistance, orientation, guidance, honesty, integrity, integrative, trustable, educates, informative, professional, versatile, adaptable, flexible, active, guide, creative, discipline, work, therapeutic relationship, curious, healthy, motivated, reflective, framing, intelligent, strength, ecological, humble, sensitize, acceptance, verbal, focused, aware, systemic, problem-solving, catalyze, assertiveness, decision-making, practical, positive, growth, development, fair, influence, self-knowledge, respectful, tolerant, reflects, cheerful and certified.

Once more, the defining words were classified into semantic categories, obtaining 48 definitions, as well as detecting those with the most semantic weight, resulting in a SAM group with the 15 most relevant categories. The authors derived these categories by considering higher frequencies and weight. The participants indicated that being empathic was the closest concept to counselor professional identity. The authors established empathic as FMG = 100, and cross-multiplied the other concepts to obtain their distance. Table 2 shows terms that professional counselors used to define counselor identity, weighted in order of relevance.

Table 2

Professional Counselors’ Identity


The resulting defining concepts also were divided into two categories: (a) the way counselors work and (b) the way counselors are. The authors believe it is important to understand how counselors actually perceived their role in their work (e.g., professional behaviors, attitudes, approaches, roles, and functions) and also the way they identify themselves personally (e.g., characteristics and abilities; see Table 3).

Table 3

Counselors’ Roles and Characteristics



It is possible to distinguish professional identity with common themes that begin during counselor training and continue as a process (Auxier et al., 2003; Balduzzi & Corrado, 2010; Brott & Myers, 1999). More similarities than differences were found comparing students and graduates.

For students and professionals, empathy occupies the most relevant place when describing counselor identity. It is interesting to observe how counselors, students and professionals prioritize values and concepts that come from a humanistic approach (e.g., empathy, authenticity, being genuine, congruent, warmth). This finding coincides with what Hansen (2003) expressed in that the counseling profession has its roots in the humanistic model, which is an undeniable part of its identity. This is also congruent with the values that the Universidad Iberoamericana promotes with students.

Ethics appear predominantly in both sets of participants, likely since professional identity and ethics are closely related (Nugent & Jones, 2009; Ponton & Duba, 2009; Skovholt & Ronnestad, 1992). Responsibility and commitment, as well as training and preparation, appear to be important defining words for counseling students and graduates, indicating that these concepts are considered fundamental. Furthermore, students and graduates consider flexibility as one of a counselor’s professional identity characteristics, which relates to versatility in counselor roles and functions. Attending to the vulnerable population and social commitment were prominent for graduates, which fortunately matches well with the mission of counseling at their university (Universidad Iberoamericana, n.d.-b).

According to the data, the concept of prevention does not emerge as a direct priority that Mexican counselors believe distinguishes them. Students mention this concept, but just once and with low relevance; however, it does not reveal itself at all as a defining term for professionals. This finding does not correlate well with actual course descriptions within the counseling master’s degree program (Universidad Iberoamericana, n.d.-a); therefore, changes in the program curricula may be needed. Students identified multiculturalism and diversity in the description of their professional identity; however, graduates did not. This distinction could be related to the recent teaching of this topic in Mexico and is expected to increase in the new generation of graduates.

It is important to note the limitations to this preliminary descriptive study. The sample was limited to 27 participants and no in-depth interviews were done in order to more comprehensively understand student and counselor perceptions. There is no basis for suggesting that the results can be generalized to other counselor populations, given that the study was specific to the particular context of one program at a private university. It is imperative to continue the study of counselor professional identity in Mexico with more participants and in-depth interviews.

There are several implications for Mexican counselor educators in regard to the development of counselor professional identity. First, there is the understanding that counselors are models in their professional activities including writing, affiliations and certification. It is imperative that educators invite students to get involved in national and international associations; promote practice, research and writing; and exalt the relevance of counselor certification.

Prevention—on the one hand a historic activity of many counselors—has proven to be a less important to Mexican counselors. To enhance this concept, the university curricula design may need to emphasize this topic in the thematic content of the program’s courses. Practica and internships might as well include prevention strategies in the student’s roles and functions. Furthermore, an elective course about prevention program design and implementation could be offered. On the other hand, it may be that prevention is a good idea, but not actually practiced by professional counselors because people tend to not pay for preventive services.

In summary, counseling students and graduates in Mexico share a common professional identity self-described as empathic, ethical, committed, versatile, trained and supportive. Efforts should be made to continue enhancing counseling core values as the profession continues to grow in Mexico, as well as internationally.


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Viviana Demichelis Machorro is a doctoral student at Universidad Iberoamericana in Mexico City. Antonio Tena Suck is the Director of the Psychology Department at the Universidad Iberoamericana in Mexico City. Correspondence can be addressed to Viviana Demichelis Machorro, Universidad Iberoamericana, Departamento de Psicología, Prolongación Paseo de la Reforma 880, Lomas de Santa Fe, 01219 México Distrito Federal, viviana.demichelis@amopp.org.